CurrentColorado Rocky Mountain Health PlansPolicy 2025R9015A

UnitedHealthcare Medicare Advantage Reimbursement Policy — CMS 1500: Additional reimbursement for Modifiers 22 and 63

Defines UnitedHealthcare Medicare Advantage reimbursement rules for services billed on the CMS 1500 form, specifically addressing additional reimbursement and documentation requirements when Modifier 22 or Modifier 63 is appended; applies to network physicians and other qualified health care professionals in Medicare Advantage products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500: Additional reimbursement for Modifiers 22 and 63

Policy CodePolicy 2025R9015A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit supporting documentation (concise statement and operative report for Modifier 22; thorough medical records/reports for Modifier 63) to request additional reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20%additional reimbursement

20100-69990eligible CPT range

CMS 1500claim form

≤ billed chargescap

Additional Reimbursement Criteria

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Additional reimbursement for Modifiers 22 and 63

UnitedHealthcare Medicare Advantage will consider additional reimbursement when modifiers 22 or 63 are appended and adequate documentation is provided.

Modifier 22 or Modifier 63 appended

ALL of the following

Additional payment equal to 20% of the Allowable Amount for the unmodified procedure, not to exceed billed charges
When both Modifier 22 and Modifier 63 are appended to the same CPT code, total additional reimbursement will be a maximum of 20% of the Allowable Amount for the unmodified procedure, not to exceed billed charges, provided documentation supports use of either modifier

Documentation requirement for Modifier 22

If Modifier 22 is appended, provider must submit a concise statement describing how the service differs from the usual and an operative report; the concise statement may be included in the operative report but must be clearly identified
Documentation must indicate substantial additional work performed and the reason (examples include increased intensity or time, technical difficulty not described by a more comprehensive code, severity of the patient’s condition, or increased physical and mental effort)
Modifier 22 should not be appended to an evaluation and management (E/M) service

Documentation requirement for Modifier 63

If Modifier 63 is appended, provider must submit thorough medical record(s) or report(s) that support use of the modifier
Documentation must indicate substantial additional work performed and the reason (examples include increased intensity or time, technical difficulty not described by a more comprehensive code, severity of the patient’s condition, or increased physical and mental effort)
Modifier 63 is generally limited to procedures/services in the 20100–69990 CPT code series and should not be appended to codes in the Evaluation and Management, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections

Modifiers and Reimbursement Details

Relevant ModifiersModifier

22	Modifier 22 — Increased procedural services (do not append to E/M services).
63	Modifier 63 — Procedures on neonates/infants up to 4 kg or increased complexity; generally for CPT 20100-69990; not for E/M, Anesthesia, Radiology, Pathology/Lab, or Medicine sections.

Additional reimbursement percentage

Additional reimbursement percentage20% of the Allowable Amount for the unmodified procedure

Cap on additional reimbursementNot to exceed billed charges

Combined modifiers ruleWhen both Modifier 22 and Modifier 63 are appended to the same CPT code, total additional reimbursement is 20% of the Allowable Amount if documentation supports either modifier

Documentation and Submission Requirements

Documentation Required

Submit concise statement, operative report, and medical records to request additional reimbursement for Modifiers 22 or 63

To request additional reimbursement when appending Modifier 22 or Modifier 63, submit the supporting documentation with the claim so UnitedHealthcare Medicare Advantage can review and determine eligibility for the additional payment (20% of the Allowable Amount, not to exceed billed charges).

For Modifier 22: a concise statement describing how the service differed from the usual and an operative report; the concise statement may be part of the operative report but must be clearly identified. Documentation must indicate the substantial additional work performed and the reason for it (e.g., increased intensity or time, technical difficulty, severity of the patient’s condition, increased physical/mental effort). (See Modifier 22 guidance.)
For Modifier 63: thorough medical record(s) or report(s) that support use of the modifier and indicate the substantial additional work performed and the reason for it (examples as listed above). Modifier 63 is generally limited to procedures/services in CPT code series 20100–69990 and must not be appended to CPT codes in the E/M, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections. (See Modifier 63 guidance.)
When both Modifier 22 and Modifier 63 are appended to the same CPT code, total additional reimbursement will not exceed 20% of the Allowable Amount for the unmodified procedure, provided documentation supports use of either modifier.
Ensure medical record documentation is submitted with the claim for review per this policy.

Key Definitions

Modifier 22 — Increased procedural services

DefinitionIncreased procedural services — a service substantially greater than typically required for the procedure as defined in the CPT book; reported by appending Modifier 22 to the usual procedure code.

Documentation requirementConcise statement and operative report documenting substantial additional work (see policy for submission details)

Not for E/M servicesModifier 22 should not be appended to Evaluation and Management (E/M) services when reporting increased procedural services.

Modifier 63 — Neonates/infants and increased complexity

DefinitionProcedures on neonates/infants up to a present body weight of 4 kg or procedures of substantially increased complexity may be reported with Modifier 63.

Code series applicabilityUnless otherwise designated, Modifier 63 may only be appended to procedures/services in the 20100-69990 code series.

ExclusionsShould not be appended to CPT codes in Evaluation and Management, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

Allowable Amount — Physician reimbursement

DefinitionAllowable Amount — the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim; may be a contracted rate, reasonable charge, or billed charges as applicable.

Percent/discount contractsFor percent of charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount.

Role in additional reimbursementAdditional payment for Modifiers 22/63 is calculated as a percentage (20%) of the Allowable Amount for the unmodified procedure.